187 Effects of de-implementation strategies aimed at reducing low-value nursing procedures 6 that most studies used multifaceted strategies including an educational component. A difference with the study of Colla et al. [7] is that our review did not identify successful multifaceted de-implementation strategies that included a clinical decision support tool and/or performance feedback in their strategy. This may be the result of different inclusion criteria and focus of the study. While Colla et al. [7] focused on successful de-implementation strategies in health services, we only included studies that assessed the effectiveness of strategies to de-implement low-value nursing procedures. To increase the effectiveness of de-implementation strategies it is recommended in the literature to use a strategy which is geared at barriers and facilitators that influence the use of low-value care [5, 16, 17]. However, this review was not able to support this recommendation since only two studies included in this review performed a barrier and facilitator assessment before executing their de-implementation strategy [9, 38]. The other studies did not describe whether they have based their de-implementation strategy on prior barrier and facilitator assessment. One study that performed a barrier assessment showed a reduction of low value nursing care (no statistical testing) [9] and the other did not show an effective de-implementation strategy [38]. The absence of de-implementation strategies that are fully connected towards factors influencing the use of low-value nursing procedures could have contributed to ineffective deimplementation strategies in this review [17]. Another way to increase the effectiveness of de-implementation strategies may be to match de-implementation strategies to the target action (stop, replace, reduce, restrict the low value nursing procedure) for de-implementation as different actions are underpinned by different theories, frameworks, and models for change as proposed by Norton and Chambers [17]. In this review most studies aimed to reduce the use of restraints. Theories of habit transformation and disruption suggest that the most effective way to reduce the use of inappropriate interventions may be to change the context and environmental cues. However, studies included in this review that aimed to reduce the use of low-value restraints mostly used educational interventions (including skills training). According to theories of individual and organizational learning and unlearning strategies, this better fits with the replacement of low-value nursing procedures. Future studies should reveal whether a better match between deimplementation strategies and target actions result in more significant reductions. This review has several strengths and limitations. The first strength is that we performed a meta-analysis to assess the effectiveness of the de-implementation strategies while Colla et al. [7] only reported whether studies were effective or not. This may have caused an overestimation of the results of the used de-implementation strategies in the
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